GYNAECOLOGICAL CAUSES OF ACUTE ABDOMINAL PAIN380 Obstetric and Gynaecological Emergencies
MANAGEMENT
1 Remove an IUCD if inserted within the last 3 weeks or if the infection is
severe. Send it for culture.
2 Admit all patients who are systemically unwell, pregnant (unusual), intoler-
ant to oral medication, have a confirmed tubo-ovarian abscess, or in whom
the diagnosis is uncertain.
(i) Start parenteral antibiotics according to local guidelines, such
as ceftriaxone 1 g i.v. daily, plus azithromycin 500 mg i.v. daily,
plus metronidazole 500 mg i.v. 12-hourly if infection was sexually
acquired.
3 Otherwise, if the patient is clinically well and the infection was sexually
acquired, give ceftriaxone 500 mg i.m., plus metronidazole 400 mg orally
b.d. for 14 days, plus azithromycin 1 g orally once, then either azithromycin
1 g orally 1 week later or doxycycline 100 mg b.d. orally for 14 days.
4 Discharge the patient and arrange follow-up in gynaecology outpatients, or a
genitourinary medicine clinic to facilitate contact screening and treatment.
(i) Contact tracing of chlamydial- or gonococcal-positive patients is
vital to prevent new and recurrent cases.
(ii) Advise patients to abstain from sexual intercourse until the
partner has been tested and treated.Ruptured ovarian cyst
DIAGNOSIS AND MANAGEMENT
1 There is sudden, moderate, lower abdominal and pelvic pain without
gastrointestinal symptoms.
2 The patient is afebrile with localized tenderness, but no mass is felt.
3 A pregnancy test is negative, and pelvic ultrasound confirms the diagnosis.
4 Give analgesia as indicated and refer the patient to the gynaecology team.Torsion of an ovarian tumour
DIAGNOSIS AND MANAGEMENT
1 Fibroids or cysts that twist or suddenly distend from a bleed cause abrupt
lower abdominal pain, often with preceding episodes of milder pain.
2 The patient may have nausea, a low-grade fever and localized abdominal
tenderness with a palpable mass.
3 Send blood for FBC, collect an MSU, and exclude pregnancy with a
pregnancy test.
4 Arrange a pelvic ultrasound, and refer the patient to the gynaecology team
for possible laparoscopy.